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Full text of "U.S. Navy Medicine Vol. 69, No. 8 August 1978"

U.S.NAVY 




August 1978 




Injury 



result 



NAVY DENTISTRY 

(see page 8) 




VADM Willard P. Arentzen, MC, USN 
Surgeon General of the Navy 

RADM R.G.W. Williams, Jr., MC, USN 

Deputy Surgeon General 

Director of Public Affairs 

ENS Richard A. Schmidt, USNR 

Managing Editor 

Ellen Casselberry 

Assistant Editor 

Virginia M. Novinski 

Editorial Assistant 
Nancy R. Keesee 

Contributing Editors 
Contributing Editor-in-Chief: CDR C.T. 
Cloutier (MC); Aerospace Medicine: 
CAPT M.G. Webb (MC); Dental Corps: 
CAPT R.D. Ulrey (DC); Education: 
CAPT S.J. Kreider (MC); Fleet Sup- 
port: LCDR J.D. Schweitzer (MSC); 
Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.A. 
Olszak; Legal: LCDR R.E. Broach 
(JAGC); Marine Corps: CAPT D.R. 
Hauler (MC); Medical Service Corps: 
CAPT P.D. Nelson (MSC); Naval Re- 
serve: CAPT J.N. Rizzi (MC. USN); 
Nephrology: CDR J.D. Wallin (MC); 
Nurse Corps: CAPT P.J. Elsass (NC); 
Occupational Medicine: CDR J.J. Bel- 
lanca (MC): Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT S.J. Kreider (MC); Research: 
CAPT J. P. Bloom (MC); Submarine 
Medicine: CAPT J.C. Rivera (MC) 



POLICY: US. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professiorjal information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy- Distribution List. The following distribution is author- 
ized: one copy for each Medical. Dental. Medical Service 
and Nurse Corps officer; one copy for every iO enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U-S, Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor. G,$. Navy Medich-.e, Department of 
the Navy, Bureau of Medicine and Surgery {Code 0010). 
Washington. D.C. 20372. Telephone: (Area Code 202) 254- 
4253. 254-4316. 254-4214: Autovon 294^253, 294-4316, 294- 
4214. Contributions from the field are welcome and will be 
published as space permits, subject to editing and possible 
abridgment. 

The issuance of this publication is approved in accordance 
with Department of the Navy Publications and Printing 
Regulations (NAVEXOS P-35). 



U.S.NAVY 




Vol. 69, No. 8 
August 1978 



1 From the Surgeon General 

2 Department Rounds 

Pharmacy Call System a Hit . . . Yokosuka's New Medical Center 
Under Way . . . 'C School Course for DTs Revamped 

5 Scholars' Scuttlebutt 

Navy Scholarships: What Can They Offer? 

6 Notes and Announcements 

8 Features 

Research in Support of Navy Dentistry 
CAPT J. F. Kelley, DC, USN 

14 A Charge to the Medical Service Corps 
CAPT P.D. Nelson, MSC, USN 

18 Training Programs for MSC Officers 

20 Empire Glacier '78 

CDR R.D. Chaney, MC, USN 

19 NAVMED Newsmakers 

24 Professional 

Incidence of Nonorganic Hearing Loss at a Military Hospital 

D.H. Dedman 

CDR J.R. Phelan, MC. USNR 

27 'Radiation Cystitis': Benign or Malignant Complication? 
LCDR R.E. Duncan, MC, USNR 

29 BUMED SITREP 



COVER: This young man received the wound shown at left from frag- 
ments of an exploding booby trap in Vietnam. Through extensive work, 
including bone grafting to restore the large defect in the patient's right 
jaw, Navy oral surgeons achieved the result at right. For a state-of-the- 
art report on research in casualty care and other aspects of Navy 
dentistry, see page 8. 



NAVMED P 5088 



From the Surgeon General 



To the Officers of the 
Navy Dental Corps 



Best wishes and congratulations! 
Birthdays are and should be happy 
occasions, and this one should be no 
less. 

You can look back upon the sixty- 
six years of your existence as a 
Corps with justifiable pride. Reflect 
with pleasure upon your contribu- 
tions, through and with the rest of 
the Medical Department, to the 
health and welfare of our Navy and 
Marine Corps. 

Progress, innovation and profes- 
sional growth have characterized 
your efforts. Your exploration and 
development of new concepts and 
new methods of dental health care 
delivery have pioneered the way for 
others to follow and have gained for 
you the respect of both military and 
civilian communities. 

The foregoing comments imply 
past accomplishments. The second 
half of a traditional birthday 




greeting includes "many happy re- 
turns,' ' which is a look to the future. 
Demands upon your energies and 
opportunities for your creative in- 
genuity, as well as requirements for 
innovative and imaginative leader- 
ship, await you. Your glorious past 
implies an illustrious future. 

Thank you for your superb per- 
formance. Happy birthday, and 
many happy returns. 



/// 




W.P. ARENTZEN 

Vice Admiral, Medical Corps 
United States Navy 



Volume 69, August 1978 



Department Rounds 



Pharmacy Call System a Hit 



For outpatient pharmacies, pro- 
viding a rapid, effective, and eco- 
nomical patient-call system to han- 
dle high-volume workloads is a con- 
tinuing problem — one for which 
improved solutions are constantly 
sought. No single system can serve 
as a model for all pharmacies; how- 
ever, we feel that other facilities 
may be interested in certain fea- 
tures of our system at NRMC Camp 
Lejeune. 

At the heart of our arrangement 
is an electronic call system with 
both visual and audio capabilities. 
We believe it to be the first such 
system to be employed by a Navy 
pharmacy service, and we have 
found it to be a definite improve- 
ment over the traditional public ad- 
dress equipment. 

The major element of the $438 
system (from Nadin Industries, 



Webster City, Iowa) is a visual dis- 
play panel, mounted in the patient 
waiting area. By means of 7-inch- 
tall illuminated digits, the panel 
tells patients at a glance that pre- 
scriptions up to and including the 
number displayed have been filled 
and are ready for pickup. Pharmacy 
technicians set the number on the 
visual display by turning three 
selector switches on a remote con- 
trol panel located at the outpatient 
dispensing window. The control 
panel also has a switch the techni- 
cian can use to sound a soft "buzz," 
alerting waiting patients when an 
additional batch of prescriptions has 
been filled. 

Other elements of the Nadin sys- 
tem are 70 feet of connecting cable 
and a standard 110-volt electrical 
cord. Installation of the system in 
our pharmacy was completed by the 




Pharmacy technicians update visual dis- 
play through selector switches on re- 
mote control panel. 



hospital's maintenance department 
in several hours' time. 

Ancillary to the Nadin system, as 
we use it, are a Bates "Lever Move- 
ment" numbering machine ($50) 
and a constant supply of disposable 
prescription claim checks. We have 
kept remnants of our old P.A. 
paging system to back up the Nadin 
system in case of breakdown, and 




PRESCRIPTIONS THROUGH 

4 7 

READY FOR PICK UP 




Electronic display panel in pharmacy waiting area. 



Hand-operated wheels update sign at dispensing window. 

U.S. Navy Medicine 



we use the P. A. occasionally to call 
individual patients when necessary. 

When a patient arrives at our 
pharmacy "turn in" window with 
new prescription forms or empty 
containers to be refilled, the techni- 
cian stamps a number in the upper 
righthand corner of the prescrip- 
tion. The same number is then 
stamped on the prescription claim 
check the patient receives, and the 
numbering machine is advanced 
one digit in preparation for the next 
patient. (At the beginning of each 
day, we reset the numbering ma- 
chine to zero after recording, for 
statistical purposes, the number of 
patients seen the previous day.) 

As prescriptions are filled, a tech- 
nician updates the visual display in 
the waiting area with the control- 
panel switches, and sets a hand- 
operated sign at the dispensing 
window that also indicates the pre- 
scriptions currently available. 

When patients come to the win- 
dow to pick up their prescriptions, 
we require them to state their 
names or present a valid identifica- 
tion card, so that their names can be 
verified with those typed on the pre- 
scription labels. 

Our patients' reactions to the 
electronic call system have been 
overwhelmingly favorable. Where- 
as we used to have frequent com- 
plaints, with our old system, that 
patients could not hear or under- 
stand the numbers announced, we 
can now constantly display the cur- 
rent number through which pre- 
scriptions have been filled. 

For our staff, setting selector 
switches on a control panel is much 
simpler and faster than making 
P. A. announcements. We find that 
the present system virtually elimi- 
nates excessive noise, makes it 
easier to keep track of the number 
of medications an individual patient 



receives, increases processing 
speed, and cuts down on patient 
waiting time. 

All things considered, we feel 
that the electronic system provides 
the best return we ever received on 



a $438 investment. 

— Story and photos submitted by LCDR 
Jerry M. Walker, MSC (chief. Pharmacy Ser- 
vice), LTJG Lee J. Barker, MSC (staff phar- 
macist), and LTJG Kenneth E. Robinson, 
MSC (staff pharmacist), NRMC Camp Le- 
jeune, N.C. 28542. 



Yokosuka's New Medical 
Center Under Way 



Groundbreaking for the new na- 
val regional medical center at Yoko- 
suka, Japan, took place on 20 May. 
VADM Willard P. Arentzen, Sur- 
geon General of the Navy, and 
Japanese construction officials par- 
ticipated in the groundbreaking, 
which followed Japanese custom, 
with Shinto priests offering tradi- 
tional prayers to the Gods for purifi- 
cation of the site and safety during 
construction. The new center will be 
adjacent to the existing hospital. 

In his congratulatory remarks fol- 
lowing the ceremony, VADM Arent- 
zen said the occasion "at once dem- 
onstrates continuing progress in 
medical care and harmony in inter- 
governmental relations. 

"The Naval Hospital, Yokosuka, 
has had a proud history," he con- 
tinued. "There have been 55 com- 
manding officers. Thirty-eight were 
Japanese, and 17 have been Ameri- 
cans, Since its founding in 1880, 
tremendous changes have occurred, 
cataclysmic events have transpired 
— brutal war and peaceful reconcil- 
iation. But through it all there has 
been a constancy of purpose, a dedi- 
cation and motivation in this institu- 
tion, which transcends all those up- 
heavals. 

"All of the men and women who 



have labored in this hospital have 
shared a common goal, have exhib- 
ited a shared humanity," VADM 
Arentzen said. "Men and nations 
differ in many ways, but they are 
alike in so many others. The broth- 
erhood of sickness and pain knows 
no racial difference, admits no lan- 
guage variation. 

"The care of the sick and injured 
is universal. And in this fine hos- 
pital we have embraced that univer- 
sal, first independently and finally 
together. For this is now a joint 
venture. The interactions and inter- 
dependence of this staff and the 
local community are important to 
each and firmly rooted in time .... 

"This new hospital, just like the 
old, will minister to the health 
needs of the sailor and his family. 
This hospital at Yokosuka in 1980 
will not really be so different from 
the hospital that was first built here 
in the 13th year of the Meiji Empire. 
It remains what it was built to be — a 
place of healing. 

"A former Commanding Officer, 
Dr. Dempsey, put it well: 'The first 
Commanding Officer and its most 
recent would understand each other 
quite well could they find them- 
selves at the bedside of the same 
sick sailor."' 



Volume 69, August 1978 



'C School Course for DTs Revamped 



At the Naval School of Dental 
Assisting and Technology, San Die- 
go, the Dental Assistant, Advanced, 
Class "C" School has recently un- 
dergone a change in curriculum to 
make the training of senior petty of- 
ficers parallel actual job require- 
ments more closely. 

The new curriculum covers both 
clinical and administrative tasks, 
and is presented through a modu- 
larized form of instruction. 

Clinical tasks. Approximately 
40% of the curriculum is devoted to 
the clinical aspect. Modules cover 
area supervision and assisting in 
advanced clinical tasks such as ap- 
pointment desk duties, oral exami- 
nation, radiology, preventive den- 
tistry, operative dentistry, oral sur- 
gery, endodontics, periodontics, 
prosthodontics, and Central Sterili- 
zation Room supervision. 

Areas of direct patient care 
covered include patient-care rec- 
ords, screening examinations, ex- 
tra-oral radiology, advanced tech- 
niques in oral hygiene, advanced 
assisting skills in support of opera- 
tive dentistry and other clinical dis- 
ciplines, and emergency repairs to 
prosthodontic appliances. 

Administrative tasks. The admin- 
istrative section of the curriculum 
includes job-related tasks in such 
areas as instructor training, clinical 
supervision, logistic support pro- 
cedures, and clerical procedures. 
These modules give the trainee the 
knowledge and skills to function ef- 
fectively in an administrative capa- 
city in a dental care facility. 

Facilities. The Naval School of 
Dental Assisting and Technology is 
designed for full support of task- 
based curriculums and provision of 
a modern clinical atmosphere. 

A laboratory that contains 40 fully 
equipped dental operatories and a 
Central Sterilization Room is used 
for the clinical modules of the cur- 
riculum. Supplemental instruction 
is provided in the facilities of Naval 



Regional Dental Center San Diego. 

Administrative modules are pre- 
sented in a classroom supplied with 
the latest office equipment and a 
complete library of reference mate- 
rials. Additional on-the-job instruc- 
tion is provided in the administra- 
tive and logistic sections of the re- 
gional dental center. 

The Dental Assistant, Advanced, 
Class "C" School, which is under 
the direction of a dental officer, in- 



cludes among its staff two senior 
dental technicians who serve as 
learning facilitators. Classes begin 
twice a year, with a capacity of 20 
students per class. 

Applications should be prepared 
and transmitted to BUMED Code 
6111 in accordance with BUMED- 
1NST 1510. 13B and TRANSMAN 
Article 2.02. 

—Story by DTC L.G. Glatt, USN. Photos 
by PH2 Don Hall, USN. 



^■£%E*^ ' 






- 


■ l 


W f^&w f i PHI 




W] ' • 












JP& A ^^- 



The Naval School of Dental Assisting and Technology occupies one of three build- 
ings in new NRDC San Diego complex. 




DT2 R.D. Blount performs a preliminary oral screening examination. School pro- 
vides a thoroughly modem clinical setting. 



U.S. Navy Medicine 



Scholars' Scuttlebutt 



Navy Scholarships: What Can They Offer? 



With the school year about to 
begin, it seems a good time to talk 
about the opportunities open to 
medical and osteopathic students 
under the Navy Health Professions 
Scholarship Program. 

Benefits. Students selected for 
these scholarships receive: 

• up to four full years of tuition, 
including all authorized fees; 

• reimbursement for approved 
books and supplies; 

• a stipend of $400 per month for 
10*/2 months of each year; 

• full active-duty pay and allow- 
ances, at the ensign pay grade, dur- 
ing 45 days of active duty for train- 
ing (ACDUTRA) each year; 

• a commission as an ensign in 
the United States Naval Reserve. 

Under current legislation, sti- 
pends, tuition, fees, and reimbursa- 
ble materials are nontaxable until 1 
January 1983 for students entering 
the program before 1 January 1979. 
(Students entering the program on 
or after the latter date are not pro- 
tected under current law). ACDU- 
TRA pay is taxable for all students. 

Benefits start on the day the stu- 
dent enters the program or the day 
the academic year begins — which- 
ever is later. 

Obligations. Health Professions 
Scholarship students are required to 
serve 45 consecutive days on AC- 
DUTRA during each fiscal year (1 
October-30 September). 



ACDUTRA time can be spent in a 
school clerkship (required or elec- 
tive), in a Navy clerkship (clinical or 
research), in a military indoctrina- 
tion course, or on an orientation 
cruise at sea. 

Men and women who have held 
Navy Health Professions Scholar- 
ships are obligated to serve two 
years on active duty for their first 
two years of participation in the pro- 
gram, or any part thereof, and six 
months on active duty for each six 
months of participation thereafter. 

Those who will be entering their 
first period of active service — or will 
be reentering active service after 
severing all previous connection 
with any military service — incur a 
minimum active-duty obligation of 
three years. 

Active-duty assignments may be 
in submarine medicine or aerospace 
medicine, aboard ships, at naval re- 
gional medical centers, at naval 
hospitals, at dispensaries and cli- 
nics, with the Antarctic Research 
Expedition, or with the Fleet Ma- 
rine Force. 

Graduate medical education. All 
Health Professions Scholarship stu- 
dents are required to apply for in- 
ternships in Navy hospitals. Those 
selected will be ordered to active 
duty and assigned to their training 
hospitals with full active-duty pay 
and allowances. 

Scholarship students not selected 



for training in a Navy facility may 
request a delay in active service to 
complete their internship (without 
pay from the Navy) in a civilian in- 
stitution. 

Students may also defer their 
active-duty obligation in order to 
complete residency training in ap- 
proved specialties. 

The time the scholarship holder 
spends in a graduate medical edu- 
cation program does not count to- 
ward fulfilling the active-duty obli- 
gation. However, he or she does not 
incur any additional service obliga- 
tion during this period. 

Selection. Students in the Health 
Professions Scholarship Program 
are selected on a competitive basis. 
Applicants must have been formally 
accepted, by a school of medicine or 
osteopathy in the United States or 
Puerto Rico, for the next entering 
class, or be currently enrolled in 
such a school. They must be citizens 
of the United States; be of good 
moral character; and meet the 
physical requirements for a Navy 
commission. 

Those who are interested in the 
program and would like details on 
how to apply should contact their 
nearest Navy Medical Corps re- 
cruiter or write to the Commanding 
Officer, Naval Health Sciences Edu- 
cation and Training Command 
(Code 9), National Naval Medical 
Center, Bethesda, Md. 20014. 



Volume 69, August 1978 



Notes & Announcements 



In memoriam , . . CAPT John D. DeCoursey, MC, USN 
(Ret.), a Navy entomologist for almost 30 years, died 20 
June 1978, at age 73. 

Born in Indianapolis, Ind., CAPT DeCoursey earned 
his Bachelor of Science degree at Louisiana State Uni- 
versity, and his M.S. and M.D. degrees in medical 
entomology at the University of Illinois. He began his 
naval career in 1942 during World War II and was as- 
signed as a malaria control officer in the Panama Canal 
Zone. He later had similar responsibilities on Okinawa. 
CAPT DeCoursey had duty at the Bureau of Medicine 
and Surgery from 1945 to 1950, and then spent four 
years at Camp Lejeune, N.C. From 1954 to 1956, he was 
stationed in Cairo, Egypt. He then returned to Wash- 
ington, D.C., until he retired in 1970. 

CAPT DeCoursey founded the Military Entomology 
Information Service, at the Walter Reed Army Medical 
Center annex in Forest Glen, for which he received a 
Defense Department commendation. He had a special 
interest in mosquitoes and was a member of the Ameri- 
can Mosquito Control Association. 



Dental continuing education courses • . . The follow- 
ing dental continuing education courses will be offered 
in October and November 1978: 

National Naval Dental Center, Bethesda, Md. 

Operative Dentistry 2-4 Oct 1978 

Oral Surgery 16-18 Oct 1978 

Oral Diagnosis and Treatment Planning 30 Oct-1 Nov 1978 

Preventive Dentistry and Patient Motivation 13-16 Nov 1978 

Eleventh Naval District, San Diego, Calif. 

Oral Diagnosis 2-4 Oct 1978 

Endodontics 16-18 Oct 1978 

Operative Dentistry 6-8 Nov 1978 

U.S. Army Institute of Dental Research, Walter Reed 
Army Medical Center, Washington, D.C. 

Endodontics 1 6- 1 9 Oct 1 978 

Prosthodontics 6-9 Nov 1978 

Armed Forces Institute of Pathology, Walter Reed 
Army Medical Center, Washington, D. C. 

Forensic Dentistry 3-6 Oct 1978 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. 92132. Applications for other dental con- 
tinuing education courses should be submitted to: Com- 



manding Officer, Naval Health Sciences Education and 
Training Command (Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should ar- 
rive six weeks before the course begins. 



Casualty treatment training available . . . The Navy 
Dental Corps conducts a continuing program of training 
in casualty care procedures. The objectives of this pro- 
gram are to provide casualty treatment training to all 
recently appointed dental officers and to provide a re- 
fresher course for career dental officers who took the 
course five or more years previously. Course dates and 
locations for Fiscal Year 1979 are: 

Naval Regional Dental Center, Great Lakes, III. Two 5-day courses 
will be offered: 23-27 April 1979, 30 April-4 May 1979 

Naval Regional Dental Center, San Diego, Calif. Four 4-day courses 
will be offered: 10-13 Oct 1978; 27 Feb-2 March 1979; 8-11 May 1979; 
7-10 Aug 1979 

Naval Regional Dental Center, Norfolk, Va. Four 5-day courses will 
be offered: 22-26 Jan 1979; 5-9 March 1979; 2-6 April 1979; 1-5 Oct 
1979 

Requests for course quotas should be submitted to 
the Naval Health Sciences Education and Training 
Command (Code 5), National Naval Medical Center, 
Bethesda, Md. 20014, via the Commanding Officer of 
the course location. Those officers in the immediate 
area of a course location who do not require travel and 
per diem expenses may submit applications directly to 
the appropriate Naval Regional Denter Center in lieu of 
the Naval Health Sciences Education and Training 
Command (Code 5). 



Continuing education for Navy nurses , . • The Naval 

Health Sciences Education and Training Command will 
sponsor the following continuing education courses for 
Navy nurses: 



Physical Assessment of the Adult (22 contact hours) 
Corpus Christi, Texas 



2-5 Oct 1978 



This program will provide the opportunity for Nurse Corps officers to 
expand their knowledge and skill in history taking and physical ex- 
amination of the adult through formal class work and practice. The 
course is planned for nurses assigned to OPD, primary care clinics, 
emergency rooms, and branch clinics. (Not for certified Nurse prac- 
titioners) 



U.S. Navy Medicine 



Middle Management Conference for Nurses (30 contact hours) 

Bethesda, Md. 23-27 Oct 1978 

The aim of this conference is to increase the organizational effective- 
ness of charge nurses entering supervisory roles through the study 
and application of basic management theory and principles. 



Neonatal Intensive Care (18 contact hours) 
Bethesda, Md. 



13-15 Nov 1978 



Emphasis will be placed on therapeutics in respiratory distress syn- 
drome. These modalities will include thermo-regulation, hypoglyce- 
mia, nutrition, fluid and electrolytes, and pharmacokinetics, as well 
as infant resuscitation, stabilization and transportation. A review of 
prematurity from identification of high-risk pregnancy through the 
process of maternal-infant bonding will be given, along with social 
service intervention in relation to the family in crisis with a sick 
neonate. 

The courses are open to Nurse Corps officers not 
currently assigned to an oversea billet. However, 
nurses assigned to Argentia, Newfoundland; Bermuda; 
Guantanamo Bay, Cuba; Keflavik, Iceland; and Roose- 
velt Roads, Puerto Rico, who have served at least six 
months on active duty, may apply. The courses are also 
open on a space-available basis to Nurse Corps officers 
of the inactive Reserve. 

Nurse Corps officers wishing to attend these courses 
should apply to the Naval Health Sciences Education 
and Training Command (Code 7), National Naval 
Medical Center, Bethesda, Md. 20014, following pro- 
cedures set forth in the BUMED Instruction 4651.1 
series. Applications should be submitted four to six 
weeks before a course begins. 



AFIP courses offered . . . The Armed Forces Institute of 
Pathology will offer the following courses: 

Ophthalmic Pathology 25-29 Sept 1978 

This course consists of a basic and comprehensive survey of patho- 
logic conditions affecting the eye. The subjects will include a review 
of the embryology of the eye; a review of general inflammation; 
acute, chronic and granulomatous lesions and their sequelae; in- 
juries; cataract, glaucoma; vascular diseases; intraocular tumors; 
optic nerve pathology; epibulbar and orbital inflammatory and neo- 
plastic lesions; and electron microscopy of the norma! and pathologic 
ocular tissues. The material will be presented by lectures and clinico- 
pathologic correlations of interesting cases. 

Applicants should be members of the Medical Corps 
of the Armed Forces or Federal Services who are board 
qualified or certified or well advanced in pathological 
anatomy of ophthalmology. Only one Ophthalmic Path- 
ology Course will be given this academic year. 



16th Annual Course in Forensic Dentistry 3-6 Oct 1978 

The purpose of this course is to acquaint attendees with situations in 
which they may be of assistance in identification and detection pro- 
cedures and to familiarize them with current aspects of professional 
liability. Subject material includes the nature and sources of the law, 
the recording and use of dental data in human identification and 
criminal detection procedures, the professional conduct and liability 
of dentists, the role of the dentist as an expert witness or defendant 
and legislation affecting the federal dental services. The course will 
be presented by specialists in the fields of forensic dentistry, criminal 
investigation and law, through lectures, panel discussions, illustra- 
tive situations and student participation in a laboratory exercise in- 
volving the identification of human remains by means of the dental 
record. 

Applicants should be federally employed dentists, 
physicians, lawyers, or law enforcement personnel who 
have a special interest in this subject. 

Applications from qualified civilian personnel will be 
considered on a space- avail able basis. Further informa- 
tion may be obtained by writing to the Director, Armed 
Forces Institute of Pathology, ATTN: AFIP-EDZ, 
Washington, D.C. 20306. 

Dental meeting held . . . The sixth annual meeting of 
the European Naval Dental Society was hosted by the 
U.S. Naval Regional Dental Center, Naples, Italy, 27-29 
May 1978 at Capri, Italy. The meeting was attended by 
21 Navy Dental Corps officers, including the dental In- 
spector General, RADM J.J. Thomas, DC, USN. The 
program included a variety of presentations by dental 
clinical specialists directed toward the continuing edu- 
cation needs of general dental practitioners. 

Navy cocktail party at ACS meeting ... In conjunction 
with the American College of Surgeons meeting in San 
Francisco, Calif., there will be a Navy cocktail party 
held on Wednesday evening, 18 Oct 1978, from 6:30 to 
9:30, at the Marines' Memorial Club, 609 Sutter Street, 
San Francisco. For more information contact: CAPT 
R.M. Deaner, MC, USN, Chairman, Department of 
Surgery, Naval Regional Medical Center, Oakland, 
Calif. 94627. 



THE SURGEON GENERAL'S SPECIALTY ADVI- 
SORY CONFERENCE WILL BE HELD 12-15 
SEPTEMBER 1978 AT THE SHERATON NA- 
TIONAL HOTEL, ARLINGTON, VA. 



Volume 69, August 1978 



Research in Support of Navy 
Dentistry 



CAPT James F. Kelley, DC, USN 



Goals: Better methods of disease prevention; improved 
treatment; more effective delivery of oral-health care. 



During its 66 years of existence, the Navy Dental 
Corps has developed a proud record of service to 
the operating forces, thanks to the professional 
excellence of its dental officers — and the enlisted tech- 
nicians and Medical Service Corps officers who help 
them meet their responsibilities. 

To maintain this level of excellence, Navy dentists, 
like other health professionals, depend on the adequacy 
of the scientific foundation that underlies their clinical 
activities. The ubiquitous nature of oral and dental 
disease and the inevitability of trauma are raisons 
d'etre for a research program that assures adequate 
scientific investigation of the problems involved in de- 
livery of dental care. 

Dental disease. Destructive dental diseases are 
among the most prevalent diseases of mankind. They 
affect virtually all the U.S. population. As a result, the 
Navy Dental Corps inherits the dental disease ills of the 
civilian populace, via naval recruits (Figure 1). 

The average naval recruit is highly susceptible to 
acute dental disease that can compromise his or her 
operational readiness. Data collected at the Naval 
Dental Research Institute, Great Lakes, 111., have 
shown that 98% of recruits have decayed teeth: that the 
average recruit comes into the service with more than 
five decayed teeth and develops one to two new lesions 
per year. 

To put it another way, 1,000 recruits will have 5,400 
decayed teeth— and 10% of these decay problems will 
be so severe that an acute dental emergency is immi- 
nent (Figure 2). During the Vietnam conflict, in fact, 
16% of the Navy and Marine forces in-country had to 
leave combat assignments for treatment of dental 
emergencies. 



From the Oral and Dental Health Program. Naval Medical Re- 
search and Development Command, National Naval Medical Center, 
Bethesda, Md. 20014. 



Acute, painful, debilitating dental disease usually 
results from the patient's neglect of oral hygiene and 
failure to seek professional attention. The ravages of 
this neglect have been well illustrated by the experi- 
ences of American POWs returned from Vietnam. The 
Navy Center for Prisoner of War Studies reported that 
individuals with a low dental health classification prior 
to captivity — implying poor oral health habits and 
avoidance of professional care — fared far worse than 
those whose oral health had been rated high. At the 
time of repatriation, 54% of those in the low classifica- 
tion required extractions or root-canal treatment, while 
just 22% who had been in the highest classification re- 
quired such care. 

The suffering of these afflicted prisoners was clearly 
reflected in the medical debriefing statement of one in- 
dividual who had seen, and endured, the sequelae of 
severe dental disease: 

"The dental problem is one of the most severe prob- 
lems faced by a prisoner of war, because of the psycho- 
logical effect of prolonged suffering from severe tooth- 
ache, which manifested itself in despair, anxiety, irri- 
tability, and inability to concentrate, even during 
periods of relief." 

Trauma. During periods of armed conflict, care of 
casualties is the most significant responsibility of the 
Navy Medical Department. 

An estimated 10% to 15% of wartime casualties suf- 
fer oral-facial wounds. (During the Vietnam conflict, 
approximately 38,000 such injuries occurred.) Because 
the oral-facial region not only comprises a complex 
milieu of organ systems but also is the focus of personal 
identity, these injuries have wide-ranging effects. 
Treatment — which is difficult, prolonged, and costly — 
must be predicated on methods that are biologically 
sound and that offer the greatest opportunity for com- 
plete rehabilitation, including return to a socially mean- 
ingful and productive life. 



U.S. Navy Medicine 




FIGURE 1. Dental condition of a naval recruit on entrance 
into service. Both tooth decay and disease of the supporting 
structures of the teeth are evident. 



FIGURE 2. Deep decay invading this tooth makes pulp 
damage likely. A debilitating emergency is imminent. 



It is essential that the ability to manage combat 
casualties continue to be developed in peacetime, to 
prevent casualty-care deficiencies in the event of any 
future conflict. 

Working in the face of these overwhelming treatment 
challenges, the Navy Dental Corps annually 
expends more than 10 million man-hours in carry- 
ing out 14.5 million dental procedures. Yet all this 
effort is not sufficient to meet the need. 

Resolving the treatment dilemma is beyond the 
capability of available resources; therefore, research 
must lead the way to better methods of disease pre- 



vention, improved treatment modalities, and a refined 
system for delivering dental health care. 

Biomedical research in the Navy is conducted under 
the Naval Medical Research and Development Com- 
mand (NMRDC), an echelon-three organization of the 
Bureau of Medicine and Surgery. The Oral and Dental 
Health Program is one of eight research programs with- 
in NMRDC and is staffed by 21 officers, 25 enlisted 
men and women, and 23 civilian employees who work in 
four different facilities. 

The principal laboratory of the program is the Naval 
Dental Research Institute (NDRI) at Great Lakes, offi- 
cially established as an independent activity on 1 Jan 




FIGURE 3A. S. Mutans on a tooth surface. The organisms 
secrete glucans, a fuzzy coating that helps them adhere to 
the tooth. 



FIGURE 3B. Tooth surface to which dextranase has been ap- 
plied. The enzyme preparation has broken up glucans, pre- 
venting accumulation of bacteria and dental plaque. 



Volume 69, August 1978 



1967. The availability of the recruit population at Great 
Lakes permits study of disease incidence as well as 
evaluation of the effectiveness of selected laboratory- 
developed treatment methods. 

Investigations are also conducted within the Dental 
Sciences Department of the Naval Medical Research 
Institute (NMRI), Bethesda, Md. Here dental officers 
have the advantage of working closely with biomedical 
scientists with widely diversified backgrounds, thus 
broadening the expertise that can be brought to bear on 
dental problems. 

At the National Bureau of Standards, just a few miles 
from the National Naval Medical Center at Bethesda, 
dental researchers have a unique opportunity to study 
the applicability of various materials to operational den- 
tistry. 

At the National Naval Dental Center (NNDC), Be- 
thesda, clinical investigation is highlighted. Graduate 
students in dentistry are given the opportunity to per- 
form research, and thus contribute to the acquisition of 
knowledge, while at the same time they gain perspec- 
tive on the value of research to clinical dentistry. 

The Navy's oral and dental health research effort 
has three centers of focus: diagnosis and preven- 
tion of oral disease; traumatic injury and surgical 
problems; and oral health care delivery. Following is a 
brief description of research initiatives in progress: 

• Tooth decay. What causes tooth decay? How can it 
be prevented? In the light of existing treatment respon- 
sibilities, these questions must obviously be addressed 
in order to reduce the operational liabilities attributable 
to dental disease. 

The major bacterial cause of tooth decay (caries) in 
naval personnel is Streptococcus mutans (Figure 3A). 
These organisms produce a fuzzy coating of glucans 
(sugar molecules in long chains) that helps them adhere 
to the tooth and form the substance known to us as 
dental plaque. Plaque localizes acids and other bacte- 
rial products that cause dental disease. One of the prob- 
lems, then, is to prevent the accumulation of glucans 
and thus keep S. mutans organisms from adhering to 
the tooth surface. 

Figure 3B shows an electron-microscope view of the 
enamel surface of a human tooth after cleaning and ap- 
plication of a substance called dextranase, which has 
broken up the glucans and prevented bacterial-plaque 
accumulation. Agents such as dextranase are being 
tested by NDRI investigators to determine their effec- 
tiveness in preventing decay in the dental-disease- 
ridden Navy population. 

• Dental-pulp studies. The "hurt" of toothache 
comes from irritation of the network of nerves and 
blood vessels that reside in the dental pulp, or 
"nerve," of the tooth. Although the pulp is extremely 
small, it is an essential structure within the tooth and, if 
severely damaged by decay or trauma, will lose its 
viability. Once this occurs, the tooth is dead tissue that 

10 




FIGURE 4. Skeletal specimen of rice-rat jaw above shows 
normal level of bone support to teeth. Specimen below shows 
severe bone loss in an animal fed a plaque-inducing diet. 



will eventually become infected, or "abscessed." 

At both NDRI and NMRI, dental investigators are 
studying the biology of the tooth pulp, in order to better 
understand its response to disease and trauma and 
determine its adaptability to various types of treatment. 

In one study, tooth substance (dentin) that has been 
invaded deeply by decay is prepared as an extract, and 
the bacteria are filtered out. The bacteria-free extracts 
are then applied to cell cultures and injected into rab- 
bits. Skin reaction indicates the presence of inflamma- 
tory response to the decayed material. 

The specific components of the diseased-tooth struc- 
ture that are toxic to tissues will be identified and 
methods of treatment developed to help the dental pulp 
survive in the face of deep tooth decay. The results of 
these studies can contribute significantly to reduction 
in the number of acute emergencies that continue to 
plague naval personnel. 

• Supporting-structure disease. Just as the teeth are 
subject to destructive processes that develop in the 

U.S. Navy Medicine 



presence of dental plaque, so also the tissues that sup- 
port the teeth (periodontium) are adversely affected by 
this microbial ecosystem (Figure 4). Both the soft tissue 
(gingiva or gums) and bone (alveolar bone) are 
damaged by diseases of the periodontium, and in some 
instances the destruction is rapid and severe. Often, 
however, the development of disease is insidious and 
not evident to the patient. 

Various types of plaque-preventing agents are being 
evaluated in the laboratory for possible testing in the 
Navy population, as a means of preventing damage to 
the supporting structures of the teeth. 

In instances where the supporting structures have 
been destroyed by trauma or disease, their reconstruc- 
tion must be attempted, to prevent loss of the teeth and 
assure satisfactory function. Studies performed at 
NNDC and NMRI have demonstrated the effectiveness 
of freeze-dried bone and soft tissue, from the Navy 
Tissue Bank, for use in reconstructing the supporting 
structures. 

Freeze-dried skin was first investigated in the labora- 
tory and then used successfully in patients to reestab- 
lish an attachment of the gingival tissue to the remain- 
ing underlying bone and thus prevent further tissue 
destruction (Figure 5). 

When the underlying bone had been destroyed, 
freeze-dried bone particles were found effective as 
bone grafts for restoring the defects and assuring ade- 
quate tooth support. 

• The dental officer's practice. How many dentists 
and dental offices do we need? how many technicians? 
These questions may seem rather straightforward, but 
if we are to mount an effective attack on the staggering 
problems of dental disease, we must determine, as ac- 
curately as possible, the circumstances in which dental 
officers can most effectively treat their patients. 

In the past, the usual type of Navy practice involved 
one dental officer working in one office with one techni- 
cian. A recent study at NDRI, evaluating various com- 
binations, showed that addition of a second operatory 
and technician for the dental officer significantly im- 
proved the dentist's efficiency and enhanced his sense 
of professional accomplishment. Realistically, doubling 
the number of dental operatories cannot be accom- 
plished overnight, and the NDRI investigators are con- 
tinuing to study various means of improving the prac- 
tice of both general dentists and dental specialists. 

• Materials of dentistry. Which type of filling is best 
for the patient? There's no single answer to this ques- 
tion. In some instances, the silver amalgam filling — or 
"restoration," as the dental officer calls it — is desira- 
ble, while in other instances gold is the material of 
choice. 

The cost of gold has always been of concern, and in 
these cost-conscious times the Dental Corps is studying 
the possibility of using various nonprecious metals in 
lieu of gold, in those instances where gold is profes- 
sionally indicated. 




FIGURE 5. Top photograph shows loss of attachment of soft 
tissue to the incisor teeth. In middle photo, a freeze-dried skin 
graft has been placed to reestablish integrity of gingival 
tissue. Bottom: Appearance of skin graft one year later. 



The National Bureau of Standards provides an ideal 
environment in which to study this question. Dental re- 
searchers are working collaboratively with scientists at 
BUSTAN, taking advantage of their expertise and the 
sophisticated equipment they have at their disposal. 

In these studies, tests are being made to determine 
whether castings made from various nonprecious 
metals will fit a die (and ultimately a tooth) as well as 
gold. The ability of the nonprecious metals to bind onto 
porcelain is also being investigated (a matter of particu- 
lar importance, because of the need for esthetic porce- 
lain facings on gold restorations in the front of the 
mouth), as is their ability to be soldered and polished. 

• Treatment of casualties. "Only the dead have seen 



Volume 69, August 1978 



11 




' I 





FIGURE 6. Upper left: Vietnam casualty at time of early care following high-velocity missile wound to the oral-facial region. 
Upper right: Patient, a civilian again, 5 years 2 months after injury. Middle left: Mandible has been reconstructed by series of 
bone and soft-tissue grafts. Middle right: Lower denture is seated on a stable, reconstructed mandible. Bottom: Panoramic 
radiograph, 52 months after injury, shows reconstructed mandible. 



12 



U.S. Navy Medicine 



the last of war, ' ' said Plato — an observation that history 
unfortunately has shown to be all too accurate. 

Successful management of complex oral-facial in- 
juries requires a thorough understanding of treatment 
principles as well as of the logistical environment in 
which patient care is being provided. Doing the right 
thing at the right time is essential to a satisfactory out- 
come when treating patients with injuries of this type. 

In an attempt to determine correct treatment princi- 
ples and the effect of logistics on outcome, investiga- 
tors at NMR1 conducted a long-term study of casualty 
care. They have summarized the results of their survey 
of Vietnam casualties in a Navy publication entitled 
Management of War Injuries to the Jaws and Related 
Structures. * An example of the treatment results re- 
ported on in the book is seen in Figure 6. 

• Radioisotopes and bone healing. Which types of 
bone graft are most effective for restoring massive loss 
of bone tissue from the jaws? What are the factors af- 
fecting the healing of these grafts? 

A major difficulty in responding to these questions 
has been the lack of an objective means for evaluating 
the process of bone repair that did not entail the sacri- 
fice of experimental animals. With this in mind, inves- 
tigators at NMRI developed a method for studying bone 
repair by employing radionuclide (radioisotope) mate- 
rials. This method permits the acquisition of objective 
numerical data, at selected intervals following bone 
grafting, without the need to sacrifice the animal or 
surgically invade the graft area. 

At selected intervals, radionuclide agents were in- 
jected into animals that had received various types of 
bone grafts to the jaws. The jaws were "imaged" by a 
camera that detected the radiation given off by the 
agent, concentrated in the area of the graft. The extent 
of healing in the graft area could then be visualized 
from the resulting images. A method of accurately 
identifying specific areas within the grafted bone in the 
images was devised, thus permitting the acquisition of 
numerical counts that reflected the extent of healing 
(Figure 7). 

This unique method has permitted better assessment 
of various types of bone grafts for oral-facial recon- 
struction. It continues to be used at NMRI to assess the 
significance of such factors as the effect of oxygen de- 
livery on the rate and quality of bone-graft repair. 

• Chronic wound infection. Chronic jaw infection is a 
problem that greatly increases the complexity and 
duration of casualty care. At NMRI, an animal model 
has been developed to study the effects of high-pres- 
sure oxygen on resolution of such infections, the ration- 
ale being that the diseased bone is deficient in oxygen 
supply and therefore refractory to treatment. 

In this study, animals were placed in a high-pressure 
chamber with a 100% oxygen atmosphere for two hours 

♦Available for S12 from the Superintendent of Documents, Govern- 
ment Printing Office, Washington, D.C. 20402. 




FIGURE 7. Image and image profile, resulting from injection 
of radionuclide materials, reflect extent of healing in bone 
grafts (arrows). 



each day, for a periof of 40 days. In the preliminary 
stages of the study, investigators found that bacteria 
introduced into experimental wounds in these animals 
to produce infection could not be cultured from the 
wounds after the 40-day period of treatment. The gross 
clinical appearance of the wounds in these animals, 
treated with high-pressure oxygen, was much im- 
proved, compared with wounds in a group of control 
animals that did not receive the oxygen therapy. 

Combating the ravages of oral and dental disease 
and assuring appropriate treatment for victims of 
trauma are the primary reasons for a program of 
research in support of the Navy Dental Corps and its 
objectives. The dedicated scientists who work in that 
program are expending their efforts to assure that Navy 
dentistry keeps pace and maintains a contemporary 
posture in a world where moon-walking has been a 
reality and where the half-life of biomedical scientific 
knowledge is but a brief decade. 



Volume 69, August 1978 



13 




A Charge to the Medical Service Corps 



CAPT Paul D. Nelson, MSC, USN 



On 1 June 1978, in my first offi- 
cial function as the seventh 
Chief of the Medical Service 
Corps, it was my privilege to deliver 
the class charge to this year's grad- 
uates of the Naval School of Health 
Sciences Program in Health Care 
Administration. Within the past 
month , once more I had the honor of 
meeting informally with — and ad- 
dressing more formally, on the oc- 
casion of their graduation— 55 of 
our newly appointed Medical Ser- 
vice Corps officers completing their 
orientation training in Bethesda. 

These two graduating classes of 
officers are important to me for 
several reasons. To be sure, they 
offered me the occasion for some of 
the more pleasant ceremonial duties 
of the Chief of the Corps. But per- 
haps more importantly, they repre- 
sent a microcosm of the Medical 




CAPT Nelson, new MSC Chief 



Service Corps, diverse in their back- 
grounds and sources of procure- 
ment, but united in their purpose. 

Some had previous enlisted ex- 
perience as hospital corpsmen and 
dental technicians; a few had served 
in the past as commissioned officers 
of the line. Still others had no previ- 
ous military experience at all. Their 
educational backgrounds ranged 
from those just short of a baccalau- 
reate (though closing in on that 
mark) to the doctorate level of train- 
ing in various allied health and sci- 
ence professions. Men and women 
were among their ranks, as were of- 
ficers diverse in ethnic and other 
cultural characteristics of our na- 
tional population. 

The second attribute of these 
graduating classes which strikes me 
as not only important but exciting 
was their sense of enthusiasm and 



14 



U.S. Navy Medicine 



commitment to the challenges they 
foresee in their roles as Medical 
Service Corps officers. Despite their 
heterogeneity in background and 
profession, they were in common 
bright, poised, earnest, and ready 
to perform, as well as to learn. 
These officers, from all sections of 
our Corps, represent the hope of our 
future. 

I cite these two classes because of 
what they symbolize. I might also 
have mentioned those Medical Ser- 
vice Corps officers recently gradu- 
ated, and with honors, from the 
U.S. Army/Baylor University Pro- 
gram in Health Care Administra- 
tion, or the numerous officers com- 
pleting graduate work in medical 
allied science fields and Health 
Care Administration related pro- 
grams at universities throughout 
the country. For they too represent 
the base of our officer corps for the 
future. Without a doubt, we have 
today the best educated officers in 
the history of the Medical Service 
Corps. For that reason, and because 
of the enthusiasm of our younger 
officers, I am optimistic about our 
future. 

Indeed, it is the future on which I 
wish us to reflect — and it is the 
spirit of a "charge," more than a 
"state-of-the-Corps" letter, that I 
feel most appropriate in this issue of 
U.S. Navy Medicine, in which we 
commemorate the 31st anniversary 
of the Medical Service Corps. 

Professor Daniel Levinson of the 
Yale University School of Medicine, 
Department of Psychiatry, recently 
authored a book which he and his 
colleagues entitled The Seasons of a 
Man 's Life. In his work to formulate 
a theoretical basis for the various 
phases and transition periods of 
adult life, Levinson's metaphorical 
theme seems strikingly applicable 
to the life of the Medical Service 
Corps as well. For we find ourselves 
in the first year of what Levinson 
calls "the age thirty transition," a 
period during which there is "an 
opportunity to work on the flaws in 
the life structure formed during the 
previous period, and to create the 
basis for a more satisfactory struc- 



ture that will be built in the follow- 
ing period." 1 That, indeed, is the 
task that presently faces us as a 
Corps of the Navy Medical Depart- 
ment. 

With each retirement, another 
element of the early Medical Ser- 
vice Corps life slips away. The valu- 
able experiences of those officers 
remain only in what was transmitted 
down. But the "conventional wis- 
dom" of the past may not be suffi- 
cient for the future. 

New problems are faced by the 
Navy Medical Department each day 
that cry out for new ideas, new tech- 
nologies, and new forms of organi- 
zation as well. These requirements 
for creativity — tempered, to be 
sure, by the practicalities of re- 
sources and the validity, in many 
instances, of professional practices 
that have withstood the "test of 
time" — are everywhere apparent in 
demands placed upon our Medical 
Department in its mission to sup- 
port the active duty forces and other 
health care beneficiaries. The role 
of education has never been great- 
er, but the need for firsthand ex- 
perience is just as great. The Medi- 
cal Service Corps officer, as a vital 
member of the Medical Department 
team, faces in all of this unprece- 
dented professional challenges. 

What are some of those chal- 
lenges? What are some of the 
new directions in which we 
must move? I have asked a sample 
of Medical Service Corps officers for 
their thoughts on these matters. 
Though few in number, the officers 
sampled represent the wide array of 
professional specialties, past mili- 
tary experience, and duty assign- 
ments that characterize the Medical 
Service Corps. Here are some of 
their thoughts: 

• It is clear that the mission, 
goals, and objectives of the Medical 
Department are being redefined for 
pursuit with increased vigor. Man- 



Levinson DJ, Darrow CN, Klein EB, Levin- 
son MH, McKee B: The Seasons of a Man's 
Life. New York: Alfred A. Knopf. Inc, 1978, 
p 84. 



power and fiscal resources will be 
realigned with the various special- 
ties needed for tomorrow's Medical 
Department mission, by program 
rather than entity. 

• It is likely that the Medical Ser- 
vice Corps could provide increased 
service by both providing and man- 
aging support functions that are not 
physician-intensive. 

• The environment in which we 
MSC officers find ourselves today, 
compared with that of those who 
preceded us, is vexatiously complex 
and technically oriented. To a much 
greater degree today than in the 
years past, health care legislation 
and numerous other public laws im- 
pact directly on what our jobs are in 
the military, and how we do them. 
This situation requires a new breed 
of MSC officer — a breed highly and 
specially trained in the new disci- 
plines of modern management the- 
ory, management control, and the 
dynamics of legislative health care. 

• The ever-increasing inflation- 
ary spiral, coupled with continued 
resource constraints imposed by 
Congress, challenges us to be inno- 
vative. We must develop methods 
to increase productivity, improve 
the quality of services, motivate 
personnel to perform at optimum 
levels, and at the same time control 
cost escalation. 

• Perhaps we can take a cue from 
the recent Operational Medicine 
Training Workshop. The proposals 
most frequently made concerning 
medical officers were: active re- 
cruiting for operational tours, early 
career operational tours prior to ad- 
vanced education above the GME-1 
level, and operational tours upon 
completion of advanced-level edu- 
cation. We also have a genuine 
need for a continuous input of 
highly qualified Medical Service 
Corps medical planners and admin- 
istrators in both the Fleet and the 
Fleet Marine Force. 

• The health care field is ever 
changing. Not only advances in 
technology, but the changing re- 
quirements throughout, dictate that 
we remain alert to these changes. It 
behooves each of us to plan for self- 



Volume 69, August 1978 



15 



development. Project your future as 
you view it; determine objectives; 
establish realistic, attainable goals 
— and then develop a program that 
will enable you to achieve them. 

• The current trend to balance 
our Corps with equal numbers from 
direct procurement and inservice 
procurement should enhance our 
effectiveness. Young, formally 
trained health care administrators 
bring to our Corps progressive, in- 
novative ideas essential to the 
health care industry. They comple- 
ment those members of our Corps 
who are selected from the enlisted 
ranks of hospital corpsmen and 
dental technicians. These individ- 
uals, former enlisted members, 
have the distinct advantage of ex- 
perience in the "Navy way" of do- 
ing things. They are seasoned, 
experienced professionals who offer 
a valuable contribution to the 
Corps. Each group has the potential 
of mutual assistance, one to the 
other. 

• In my view there is one major 
problem confronting the Medical 
Service Corps today, particularly 
the Allied Science Section. That is 
the lack of, or insufficient potential 
for, increasing responsibilities as 
our individual officers progress in 
grade or experience. There is a 
need to increase management skills 
of allied science Medical Service 
Corps officers. 

• The Medical Service Corps 
HCA section has a billet structure 
that resembles a sawed-off pyra- 
mid. While we have an overwhelm- 
ing number of billets at the middle- 
management level, there are too 
few opportunities in higher-level 
management positions for those in- 
dividuals who have demonstrated 
management talent. 

• It is incumbent upon the Medi- 
cal Department to identify those 
positions within senior management 
that require professional expertise 
as well as administrative ability. 
Many of these positions could be 
filled equally well by qualified indi- 
viduals, regardless of their Corps 
subspecialty. Every effort should be 
made to select those individuals 




One Corps, many specialties. Among them: environmental health 



most qualified to perform these 
jobs. 

• Billets for Medical Service 
Corps officers with the Marine 
Corps have increased over the past 
few years, not only in numbers, but 
in levels of responsibility. Within 
the active Fleet Marine Force, there 
are 21 command billets in medical 
companies, hospital companies, 
medical logistics companies, and 
medical battalions. The medical 
companies offer the unique oppor- 
tunity for young officers at the lieu- 
tenant/lieutenant (jg) levels to ex- 
perience the responsibilities of com- 
mand. These billets can and should 
serve as an initial training ground 
for the development of future com- 
manders of larger Fleet Marine 
Force or Navy medical units. Com- 
mand of an entire medical battalion 
— with its 540 beds, 16 surgeries, 
ancillary medical services, commu- 
nications, motor transport, supply, 
food service, graves registration, 
and administration — provides the 
more senior officer the full gamut of 
command responsibilities found in 
any major line or staff community. 

• "There are many members, 
but one body." I use this quotation 
from the Bible, 1 Cor. 12:20, to il- 



lustrate how I view the Navy Medi- 
cal Service Corps — there are many 
specialties, but one Corps. These 
many specialties are the strengths 
and the weaknesses, as I see them, 
in the Medical Service Corps. 

There are 21 specialties in six sec- 
tions in the MSC. These specialties 
give our Corps great diversity and 
provide the Navy Medical Depart- 
ment with a broad expanse of ex- 
pertise in many professional occu- 
pations. This is definitely a 
strength. So why is diversity a 
weakness? 

Let's look at one area — career 
patterns and progressions. Due to 
the nature of some of our specialties 
and the number of billets within the 
specialty, there are no definite 
career patterns, and the opportunity 
for progressing to more meaningful 
and responsible positions is ex- 
tremely limited. 

I prefer not to be negative about 
the Medical Service Corps because I 
think there are many bright spots. I 
think the quality of the new people 
coming into the MSC is tops in all 
the specialties. There are more 
management opportunities because 
of the shortage of physicians. Re- 
cently a number of staff billets for 



16 



U.S. Navy Medicine 





. . . medical technology 

MSCs have been made available in 
Line commands. These are all good 
things that are happening to our 
Corps. 

• I envision the Medical Service 
Corps continuing to play a vital role 
in our Navy's health care delivery 
system. The emphasis remains on 
"TEAM" work — in the Medical 
Department, in the Navy, and in the 
Marine Corps. I would urge each 
officer to review his or her responsi- 
bility in this endeavor. 



. . . aviation physiology 

To address those challenges, we 
must work together, not only as 
members of one Corps of offi- 
cers, across different professional 
specialties, but together, as one 
Medical Department, across our dif- 
ferent Corps as well. We must be 
naval officers first! For that is our 
profession, too. 

We must in the year ahead 
closely examine the various roles in 
which we currently function, and 
identify, as well, those in which our 
services are required but not pre- 
sently offered. We must realign as 
necessary the structure of our 
billets with the requirements that 
are identified under current opera- 
tions, as well as for various contin- 
gencies of support required by the 
operating forces, Navy and Marine 
Corps alike. 

We must work closely with other 
members of the Medical Depart- 
ment in developing these staffing 
concepts and plans, as we must also 
do in our review and development of 
new opportunities in training and 
continuous education. Another arti- 
cle in this issue addresses some of 
those training opportunities, which 
require closer linkage to billet re- 
quirements than in the past. 

We must put greater emphasis on 
career patterns and alternative ca- 



reer path options, such as to in- 
crease the sense of professional 
challenge and responsibility for 
officers in all sections of our 
Corps — and also to achieve greater 
flexibility in the assignment poten- 
tial of our officers, without sacrifice 
of quality in their professional de- 
velopment or performance. This is 
not to say that there will be one 
mold for all officers; on the con- 
trary, the goal is to achieve better 
planning while at the same time 
allowing for more diversity in ca- 
reers. This will not be easy to 
achieve, but must receive our full 
attention. 

To begin working in these direc- 
tions, I plan to reorganize the Corps 
directorate this fall. I am bringing 
onto my staff two senior officers — 
CAPT Ann Hatten and CAPT- 
selectee Vic Swindall — to serve as 
Deputy for Allied Health and Sci- 
ence Professions and Deputy for 
Health Care Administration and 
Management Professions, respec- 
tively. (Of our total Corps strength, 
approximately 1,800 officers, about 
half are in each of those general 
professional areas.) Through their 
able leadership, I hope to expand 
the present base of professional 
specialty consultants and, indeed, 
the base of participation among all 
officers of the Medical Service 
Corps, junior and senior, hospital 
and fleet, research and health care. 
We will want your ideas; we will 
need your help. We will expect your 
commitment to the challenges 
ahead, if we are to get the job done 
as others have in the past. I know 
we can count on each of you in that 
endeavor, and I thank you, each 
one, for your support as we move 
together — many talents, one team, 
one spirit. 

That is my charge. 
Happy Birthday! 

On behalf of the Medical Service 
Corps officers of the U.S. Navy, it 
gives me great pleasure as well to 
extend a Happy Birthday greeting 
to our Navy Medical Department 
colleagues of the Dental Corps who 
share our anniversary month of 
August. 



Volume 69, August 1978 



17 



Training Programs for MSC Officers 



Educational programs available 
to Medical Service Corps officers in- 
clude full-time training, part-time 
training, and continuing education. 
All Medical Service Corps officers 
are encouraged to become familiar 
with these programs and participate 
in them to the fullest extent possi- 
ble. 

Full-time training. In addition to 
training in civilian institutions at the 
undergraduate, graduate, and doc- 
toral level, other programs include: 
the Blood Bank fellowship at Walter 
Reed Army Medical Center; phar- 
macy residency programs at the 
National Naval Medical Center, 
Bethesda, Md., and at NRMC San 
Diego; the podiatry residency at 
Naval Hospital Beaufort, S.C., and 
the U.S. Army/Baylor University 
Program in Health Care Adminis- 
tration at Fort Sam Houston, Tex. 

Also available are the Health 
Care Administration Course, the 
Financial and Supply Management 
Training Program, and the Patient 
Services Training Program at the 
Naval School of Health Sciences, 
Bethesda; the Naval Postgraduate 
School, Monterey, Calif, (curricula 
primarily in finance, personnel 
management, and automatic data 
processing); and various service 
schools such as the Armed Forces 
Staff College, the Industrial College 
of the Armed Forces, and others. 

Application procedures are out- 
lined in BUMEDINST 1520. 12G. 
Applications for all full-time train- 
ing, except for those programs indi- 
cated below, must be submitted to 
the Commanding Officer, Naval 
Health Sciences Education and 
Training Command (HSETC), no 
later than 15 October of each year. 

Requests for programs at the 
Naval War College, Armed Forces 
Staff College, Marine Corps Devel- 
opment and Education Command, 
Industrial College of the Armed 
Forces, and Field Medical Service 
School should be sent directly to the 



Chief, BUMED (Code 71), since 
assignment to these programs usu- 
ally requires post-training assign- 
ment to specifically identified bil- 
lets. 

It is recommended that requests 
include the exact start and comple- 
tion dates of the training requested, 
all transcripts and test scores (re- 
quired for consideration for the 
USA/Baylor program). Since a let- 
ter of acceptance is not always ob- 
tainable in time to meet the above 
deadline, a statement from the in- 
stitution, indicating that the appli- 
cant has taken some action to gain 
admission, will suffice. An alterna- 
tive course of action would be to 
apply to an institution a year in ad- 
vance and then defer the acceptance 
until approved by the Medical 
Service Corps Training Board for 
the following year. 

Selection to full-time training is 
based upon several factors. First 
and foremost are the projected 
staffing needs of the Medical Ser- 
vice Corps. 

The second factor is availability of 
the applicants. It is Navy policy that 
projected rotation dates be strictly 
adhered to. An officer should not 
expect to have a tour of duty prema- 
turely curtailed so that he may enter 
full-time training. 

Part-time training. The Part-Time 
Outservice Training Program gives 
Medical Service Corps officers an 
alternative to full-time training as a 
means of raising their educational 
level. While many of the participat- 
ing officers are working on their 
bachelor's degrees, an increasing 
number are working for master's 
degrees and doctorates. 

The part-time training program 
also permits those officers inter- 
ested in full-time training to begin 
advance work on their degrees prior 
to selection for full-time training. 
This reduces both the financial and 
time-to-degree-attainment support 
needed, and in some cases en- 



hances the applicant's request for 
full-time training support. 

The part-time training program 
provides partial sponsorship to offi- 
cers taking evening or weekend 
courses in accredited civilian insti- 
tutions. Courses requested must be 
in an area directly related to areas 
of Medical Department responsibil- 
ity and associated with a degree- 
attainment program. The degree 
should be in one of the physical, 
chemical, clinical, biological, or 
socio-psychological sciences or 
fields associated with Medical De- 
partment administration. 

Officers participating in this pro- 
gram must agree to remain on ac- 
tive duty for two years following 
completion of the approved course. 
BUMEDINST 1500. 7D is the appli- 
cable instruction for this program. 

Continuing education. With rapid 
changes in the technology, adminis- 
tration, and delivery of health care, 
and with greater emphasis on ac- 
countability, continuing education 
is essential for maintaining profes- 
sional competence. 

Participation in professional-up- 
date short courses and seminars is 
one means by which Medical Ser- 
vice Corps officers can keep abreast 
of the latest advances and events in 
their professions. This participation 
also keeps MSC officers aware of 
the activities and problems of their 
counterparts in the civilian sector. 

Guidelines and procedures for 
participation in continuing educa- 
tion programs are contained in BU- 
MEDINST 4651. IB. 

Contact for further details. LT 
Jeffrey A. Kramer, MSC, USN, Di- 
rector, Medical Service Corps Pro- 
grams, is available to assist with 
problems or questions that may 
arise. He can be contacted at the 
Naval Health Sciences Education 
and Training Command (Code 6), 
National Naval Medical Center, 
Bethesda, Md. 20014; Autovon 295- 
0625, Commercial (202) 295-0625. 



18 



U.S. Navy Medicine 



IMAVMED Newsmakers 




LT Pope: elan 



Photo by John Baeheller 



Some people may think of psychiat- 
ric nursing as depressing, but not 
LT Carolyn Pope (NC), a charge 
nurse in the psychiatric department 
at NRMC Portsmouth, Va. 

For most of her eight years in 
nursing, she's worked with psychi- 
atric patients and in drug rehabilita- 
tion. "It's work I enjoy," she says. 
"I can see the progress the patients 
are making." 

Asked if, as a Black, she's en- 
countered prejudice in the Navy, 
she answers with a candid yes. "At 
first it really caused me to have cul- 
tural shock. Then I realized that 
people are people, in uniform or out 
of uniform. . . . 

"I've been very fortunate in 
having a nursing director and as- 
sistant director whom I can really 
talk with. I've found that some 
problems are because I'm Black and 
others are just because I'm me, a 
female who's sometimes very out- 



spoken and likes to move . . . get 
things done," she says with a grin. 
LT Pope is a woman who handles 
her life with eMan. And through her 
profession, she's hard at work help- 
ing others learn to do likewise. 

LCDR Oloff L. Hansen (DC) has 

good reason to smile, having been 
awarded the Navy Achievement 
Medal for his performance while 
serving as dental officer of Marine 




LCDR Hansen: initiative 

Aircraft Group 24, 1st Marine Bri- 
gade, in Hawaii. 

Throughout that assignment, 
says his citation, Dr. Hansen "con- 
sistently performed his demanding 
duties in an exemplary and highly 
professional manner. Displaying 
exceptional initiative and resource- 
fulness, he continually provided 
outstanding dental service, and was 
instrumental in obtaining and im- 
plementing the use of a mobile 
dental van. . . . His program re- 
sulted in saving untold man-hours 
by having dental service available in 



the immediate vicinity of each 
squadron." 

Dr. Hansen is currently assigned 
to the Marine Air Station at El Toro, 
Calif. 

CAPT Clarence J. Gibbs, Jr. (MSC, 
USNR-R), a distinguished micro- 
biologist known for his work with 
slow viruses, has been named to 
represent the Navy Medical Depart- 
ment's Reserve component on the 
executive council of the Association 
of Military Surgeons of the United 
States. He is responsible for de- 
veloping the first Naval Reserve 
medical program for the annual 
AMSUS meeting, to be held later 
this year. 

Dr. Gibbs is deputy chief of the 
Laboratory of Central Nervous Sys- 
tem Studies, National Institute of 
Neurological and Communicative 




CAPT Gibbs: more honors 

Disorders and Stroke. Within the 
past year, he was awarded an 
honorary doctorate in medicine 
from the Faculte de Medicine, Uni- 
versity of Marseille, France — be- 
lieved to be the only honorary medi- 
cal degree to be held by a Navy 
MSC member. 



Volume 69, August 1978 



19 



Empire Glacier '78 

Medical aspects of a cold-weather exercise 



CDR Robert D. Chaney, MC, USN 



Early this year, LT Bill Boggs 
(MSC) and I joined units of the 
1st Battalion, 6th Marine Regi- 
ment, for Empire Glacier '78, a 
cold-weather training exercise at 
Fort Drum, N.Y. 

During the period of the exercise 
(9 January through 2 February), we 
spent a number of days living in the 
field with units from the battalion 
landing team, in order to experience 
firsthand the stresses inflicted on 
the Marine exposed to cold. Weath- 
er conditions ranged from deep, dry 
cold to moderate, wet cold, with 
temperatures from -17°F to 40 °F. 

After we had been taught how to 
build temporary field shelters, we 
and our Marine friends set out on 
snowshoes, with a full field pack, 
for our first overnight stay in the 
snow. Despite our natural appre- 
hensions, we all quickly learned that 
we could survive in this hostile envi- 
ronment with a minimum of discom- 
fort. After this first experience with 
makeshift shelters, arctic tents and 
Yukon or squad stoves were pro- 
vided, so subsequent life in the field 
was relatively cozy. 

Before their departure from 
Camp Lejeune, N.C., the Marines 
had been thoroughly briefed on 
survival in the field, with emphasis 
on good cold-weather preventive- 
medicine measures, such as wear- 
ing appropriate clothing, changing 
socks frequently, and using the 
vapor-barrier "Mickey Mouse" 
boots. The troops were also warned 

CDR Chaney is a member of the Depart- 
ment of Experimental Medicine/ Anesthesi- 
ology at the Naval Medical Research Insti- 
tute. Bethesda, Md. 20014. 



about overheating during exertion 
in cold weather, leading to hypo- 
thermia during rest, and about the 
hazards of dehydration, constipa- 
tion, etc. 

On our arrival at Fort Drum, LT 
Boggs and I set out to reinforce 
these instructions with many small 
briefings that included such guide- 
lines as, "Every time you eat, 
change your socks — more frequent- 
ly if needed." These briefings were 
aimed primarily at preventing frost- 
bite and maceration of the tissues. 

Frostbite occurs when the feet 
become increasingly cold, until 
tissue actually freezes. Vapor-bar- 
rier boots can keep the feet rela- 
tively warm as long as the wearer is 
active. However, when vigorous ex- 
ercise is followed by a period of in- 
activity, during which the feet cool 
off, these boots will, in fact, keep 
the feet cold. Moreover, perspira- 
tion accumulating in the vapor- 
barrier boots, when they are worn 
indoors or in temperatures warmer 
than those for which the boot was 
developed, will result in softening 
and maceration of the tissues. 

All these problems can be pre- 
vented by frequent sock changes, 
preceded by carefully drying the 
feet and toes, then dusting them 
with an absorbent powder. (Recent- 
ly, solutions of 50% aluminum chlo- 
ride in alcohol have been recom- 
mended to prevent foot sweating.) 

Proper foot care was given great 
emphasis by the battalion com- 
mander, who was quite knowledge- 
able about cold-weather medical 
problems. Squad leaders conducted 
nightly foot inspections in the field, 



and questionable injuries were re- 
ported to the corpsmen, who in turn 
reported them to us. The squad 
leaders and corpsmen quickly be- 
came expert in recognizing early 
signs of cold injury. 

We were fortunate in having the 
full cooperation of the battalion 
commander, so that daily briefings 
to the company commanders in- 
cluded our input on anticipated 
problems from the medical stand- 
point — e.g., dehydration during the 
upcoming exercise, overheating, 
and the possibility of constipation as 
a result of three days of "C" ra- 
tions, inadequate fluid intake, and 
natural reluctance to defecate in the 
cold, snowy outdoors. Careful ob- 
servation of the "snow flowers," in 
fact, provided a fairly accurate indi- 
cation of the state of hydration. 

Our second sojourn in the field 
lasted five days, during which LT 
Boggs and 1 made frequent checks 
of the various companies through 
the company corpsmen. This not 
only gave the corpsmen an opportu- 
nity for consultation in the field but 
also served to relieve anxieties 
among the Marines, who quickly 
learned that at no time were they far 
from medical help and evacuation, 
should either become necessary. 

This was pointed out rather dra- 
matically during the first few 
nights. Several Marines with very 
cold feet ("frostnip") were dis- 
covered, sent to the battalion aid 
station (BAS), rewarmed complete- 
ly, then returned to the bivouac 

Nothing's easy when the temperature is 
low and the wind-chill factor is high. 



20 



U.S. Navy Medicine 




Arrival at bivouac site— temperature -5°F. 



area. This had several good effects. 
The individuals in question found 
that they could and would be evacu- 
ated to the rear if medical necessity 
demanded it. They also learned that 
their injuries were reversible and 
could be adequately treated at the 
BAS level. At the same time, they 
learned that having cold feet alone 
did not relieve a man of his tempo- 
rary obligation to live and sleep in 
the field. 

Throughout the exercise, the U.S. 
Army provided backup medical fa- 
cilities at the cantonment area for 
the 15,000 Army, Air Force, and 
Marine personnel involved. A 
MUST (medical unit, self-con- 
tained, transportable) hospital with 
surgical capabilities was erected to 
handle the more serious injuries. 
(No surgery was performed on 
Marine personnel.) Prior to estab- 
lishment of the MUST, a fractured 
ankle was treated at the civilian hos- 
pital in Watertown and the patient 
was returned to Fort Drum on 
crutches. 

During the mock war the troops 
were engaged in, a forward BAS 



was established in the field to deter- 
mine the need for casualty evacua- 
tion to the cantonment BAS 52 miles 
away. 

I am happy to say that the time 
spent in preventive medicine at all 
levels was not wasted. There were, 
of course, exceptions. In a few 
cases, persons "too busy" to com- 
ply soon found that what had been 
told them was quite true. For exam- 
ple, one man who had joined the 
outfit just days prior to departure, 
and who said he "wasn't told you 
had to change your socks more than 
once a day," presented with gross 
maceration of superficial skin over- 
lying the tarsal-metatarsal area. He 
was returned to the cantonment 
area for definitive therapy, consist- 
ing of bedrest and open technique 
for the care of the seeping areas. 

Another man, having been issued 
two "inner" sleeping bags, elected 
to take only one to the field. After 
breaking the zipper during the 
night, he slept partially exposed 
and was brought to the BAS in an 
ahkio sled, with very early frostbite 
of both fingers and toes, manifested 



by edema without blister formation. 
He had a rectal temperature of 
35°C. He was evacuated to the rear 
and responded to warm-water thaw- 
ing of the affected digits. His mild 
hypothermia was treated by bun- 
dling him info two sleeping bags in 
a heated ambulance en route to the 
cantonment area BAS. 

In all, seven persons with early 
frostbite were evacuated to the rear. 
All responded well to warm-water 
therapy. No case of frostbite or 
hypothermia required hospitaliza- 
tion beyond the BAS level. 

Several "flu" syndrome cases 
were diagnosed in the field and 
quickly evacuated to the rear BAS to 
prevent further spread of the dis- 
ease in the confinement of the arctic 
tents. 

As might be expected, the great- 
est number of maladies involved the 
upper respiratory tract. Men with 
these illnesses were treated at the 
BAS in the field and were usually 
returned to duty. One man with 
bronchitis and one with pneumonitis 
required "sick in quarters" for 3-4 
days. Both responded well to ther- 



22 



U.S. Navy Medicine 



apy and were returned to duty. 

During most of the field exer- 
cises, the troops skied or snowshoed 
into the bivouac area. During the 
"war," they were conveyed to the 
area by truck or helicopter and con- 
tinued on "foot." Several minor 
injuries occurred among men learn- 
ing to ski, the most serious of these 
being a fractured ankle. One man 
was evacuated to Camp Lejeune be- 
cause of deep thigh lacerations sus- 
tained in a fall on a piece of equip- 
ment. And one Marine required the 
services of an ophthalmologist for 
eye injuries sustained when a tin of 
"C" ration peanut butter exploded 
on a stove. This was the only 
Marine who needed to be referred 
to the MUST hospital. 

One potentially serious accident 
occurred, but without serious se- 
quelae, thanks to the repeated 
medical briefings. While crossing a 
stream, a Marine fell through the 
ice and was immersed in water up to 
his waist. Corpsmen and fellow 
Marines immediately removed his 
wet clothing, wrapped him in a 
sleeping bag, and air-evacuated 
him to the BAS in the rear, where 
he was treated and released before 
word of the event reached us. 

A potential medical catastrophe 
was averted by cool heads and com- 
pliance with instruction. While we 
were in the field on the march, after 
several days of near-zero weather, 
we were hit by 36 hours of continu- 
ous rain, followed by a quick freeze. 
Using the warming methods avail- 
able, everyone succeeded in drying 
his gear, so that despite the 
potential for multiple cold-weather 
injuries, only a few mild hypother- 
mia cases resulted. 

A word about evacuation: Casual- 
ties could be taken by ahkio sled, 
via the field BAS, to the nearest 
paved road or could be air-evacu- 
ated by helicopter. As it turned out, 
however, helicopter evacuation was 
used only to transport the immer- 
sion victim to the rear, while the re- 
maining evacuations were carried 
out by ambulances stationed at the 
forward BAS. 

LVTs (landing vehicle, tracked) — 




Pine boughs, string, and poncho make a shelter. 




Unloading supplies is one way to keep warm. 



the only vehicles capable of moving 
over extremely deep, wet snow — 
stood by for evacuations in case the 
weather put a stop to flying. How- 
ever, except for an occasional 
"frostnip" case, evacuated in the 
normal course of returning an LVT 
to base, this method was not used. 
Nevertheless, to those of us charged 
with the medical care of 2,000 Ma- 
rines, it was very comforting to 
know that such a foolproof evacua- 
tion vehicle existed. 

To summarize: In a four-week 
period a battalion-sized Marine unit 



became acclimated to an entirely 
hostile, foreign environment and 
found it could not only exist but 
could also conduct offensive and 
defensive maneuvers with relative 
ease and with only minor, transient 
casualties. But without proper infor- 
mation, lectures, and repeated pre- 
ventive medical briefings at all 
levels, by interested, qualified med- 
ical and paramedical personnel 
cognizant of cold-weather medical 
problems, serious injuries — and 
possibly death — could have oc- 
curred. 



Volume 69, August 1978 



23 



Professional 



Incidence of Nonorganic Hearing Loss 
at a Military Hospital 



David H. Dedman CDR J.R. Phelan, MC, USNR 



Nonorganic hearing loss, whether it is voluntary 
(malingering) or involuntary (psychogenic), occurs 
more frequently in the military than in the civilian 
population. There are many opportunities in the mili- 
tary to gain from an alleged hearing loss. A chance for 
monetary compensation, relief from unwanted duty, 
and discharge from the service are only a few reasons 
why exaggeration of a hearing loss may be tempting to 
military personnel. 

Nonorganic hearing loss has been prevalent in Vet- 
erans Administration and military hospitals for more 
than 30 years (1,2,3,4). Examiners' awareness of the 
frequency of this problem — and the many audiometric 
tests available to detect it — combine to allow very few 
of these cases to go undetected in the VA and military 
setting. This high rate of detection of the problem, how- 
ever, does not seem to discourage its incidence. 

Nonorganic hearing loss was first recognized, and its 
importance to the Federal Government first noted, in 
the Armed Forces aural rehabilitation programs during 
and after World War II (/), The magnitude of this prob- 
lem for the government is evident in the veteran popu- 
lation alone. It has been estimated that from 11% to 
45% of veterans with a service-connected hearing loss 
demonstrate a nonorganic hearing loss or overlay in 
their hearing thresholds (2). Since the federal govern- 
ment may award various types of compensation for ser- 
vice-connected hearing impairment, exaggerated hear- 
ing loss can be costly. 

The data presented in this study were collected at the 
Otolaryngology Clinic at NRMC Great Lakes, III., over 
an 18-month period (June 1976 to December 1977). The 
subjects have been separated into three groups: re- 



From the Department of Otorhinolaryngology, NRMC Great Lakes, 
III. 60088, where Mr. Dedman is director of audioSogy and CDR 
Phelan is chief of otolaryngology. 



TABLE 1. Incidence of Nonorganic 
Hearing Loss in Subject Groups 


Subjects 


Number 


Nonorganic 
Hearing Loss 


Recruits 

Retired /active duty 

Dependents 


512 
1,404 
1,025 


382 (74.6%) 
229 (16.3%) 
127 (12.4%) 


TOTAL 


2,941 


738 (25.1%) 





cruits, retired and active-duty personnel, and depen- 
dents of retired and active-duty personnel. This group- 
ing provides some idea of the incidence of nonorganic 
hearing loss in various populations. 

Method 

Our audiometric criteria for nonorganic hearing loss 
consisted of failure on three or more of the following 
audiometric procedures: pure tone and speech audio- 
metric correlation, electrodermal audiometry (EDA), 
presence of the stapedial reflex, the Stenger test, 
Bekesy audiometry (Type V), the diversion of auditory 
task test (DAT), and a speech discrimination test below 
alleged thresholds of hearing. Usually a discrepancy 
between pure tone and speech reception thresholds, 
not explainable by the configuration of the audiogram, 
is one of the first indications of a nonorganic hearing 
loss or overlay to the examiner. 

The subjects evaluated in this study were 2,941 indi- 
viduals referred to our clinic because of an apparent 
hearing problem. The subjects were not randomly 
sampled, but rather were individuals complaining of a 



24 



U.S. Navy Medicine 



hearing disorder. The incidence of nonorganic hearing 
loss in such a group is significant to clinics and hospi- 
tals that see referred patients. In this type of subject, 
this incidence is higher than in a random sample of in- 
dividuals, since the majority of nonorganic hearing loss 
cases involve exaggeration of an existing hearing diffi- 
culty (2,5,6). 

Results 

Nonorganic hearing loss was identified in 738 
(25.1%) of the 2,941 subjects evaluated (Table 1). This 
percentage was greatly inflated by the high incidence of 
nonorganic hearing loss in the recruit population. Dis- 
regarding the recruit group and considering only the 
2,429 retired, active-duty, and dependent subjects, 
nonorganic hearing loss was identified in 356 (14.7%). 

• Recruit population. The subjects evaluated in this 
study included 512 U.S. Navy recruits, ranging in age 
from 17.2 to 21.3, with a mean age of 18.2 and a median 
age of 18.7. Three hundred and eighty-two (74.6%) of 
these recruits demonstrated some exaggeration of 
hearing loss in one or both ears (Table 1). A majority 
(56.4%) demonstrated a bilateral nonorganic hearing 
loss. Twenty-four (6.1%) of the 382 individuals in the 
nonorganic group had bilateral normal hearing. Twenty 
(83.3%) of these 24 had an alleged unilateral hearing 
loss. 

• Retired and active-duty personnel. Also included 
in our study were 1,404 retired and active-duty person- 
nel from all the Armed Forces, ranging in age from 17.8 
to 78.6, with a mean age of 42.3 and a median age of 
38.5. In this group, 229 individuals (16.3%) had non- 



organic hearing loss or overlay in one or both ears (Ta- 
ble 1). The majority of nonorganic hearing impairments 
in this group also were bilateral: 146 (63.6%) of the 229 
demonstrated an exaggeration of hearing loss in both 
ears. None of the 229 exhibited normal hearing bilater- 
ally (Table 2). 

Of the 229 individuals exhibiting nonorganic hearing 
loss, 166 (72.3%) were between 42 and 62 years of age; 
thus nonorganicity was displayed more frequently by 
the older members of this group than by the younger 
ones. 

• Dependents. Our third group of subjects consisted 
of 1,025 dependents of retired and active-duty person- 
nel from all the Armed Forces. These subjects ranged 
in age from 6.2 to 71.6, with a mean age of 34.6 and a 
median age of 23.6. Dependents under the age of 6 
were not included in our data. The rarity of nonorganic 
hearing loss in children under 6, and the sometimes 
questionable reliability of hearing-threshold determina- 
tions for these individuals, prompted their exclusion 
from our data. 

Of the 1,025 dependents studied, 127 (12.4%) had a 
nonorganic hearing loss or overlay (Table 1). Among 
those 127 were 71 (55.9%) with an alleged bilateral loss 
of hearing (Table 2). Nine (7.0%) of the 127 had bilat- 
eral normal hearing. Seven (77.7%) of these 9 claimed 
a unilateral hearing loss. 

Discussion 

We were interested in finding the incidence of non- 
organicity in individuals complaining of a hearing loss. 
We expected the incidence to be higher in these indi- 





TABLE 2. Type of Nonorganic Hearing Loss 


n Subject Groups 




Subjects 


Nonorganic 
Loss 


Alleged 

Unilateral 

Loss 


Alleged 
Bilateral 
Loss 


Bilaterally 

Normal 


Recruits 

Reti red / active duty 

Dependents 


382 
229 
127 


143 (37.5%) 
83 (36.4%) 
71 (55.9%) 


215 (56.4%) 

146 (63.6%) 

47 (37.1%) 


24 (6.1%) 

None 
9 (7.0%) 




TOTAL 738 


297 (40.2%) 


408 (55.3%) 


33 (4.5%) 





Volume 69, August 1978 



25 



viduals, and this was certainly true of our recruit popu- 
lation. It was also true, to a lesser degree, of the other 
two groups. 

The high percentage (74.6%) of nonorganic hearing 
loss in our recruit population was not unexpected. This 
group is highly motivated to exaggerate hearing prob- 
lems in order to ease the stressful training situation 
with which they are confronted. The incidence of non- 
organic hearing loss in our recruit population is much 
higher than in any other group we have evaluated. In 
1956, Johnson et al. (2) estimated that between 11% 
and 45% of all veterans with service-connected hearing 
losses exaggerate their loss, but even Johnson's 
maximum percentage is well below the 74.6% found in 
our recruits. 

The retired and active-duty group demonstrated a 
much lower incidence of nonorganic hearing loss 
(16.3%) than the recruit group. The 16.3% is well with- 
in Johnson's estimate. 

In the retired and active-duty group, the vast major- 
ity of cases of nonorganic hearing loss were found 
among individuals 42 to 62 years of age. This may be 
because many individuals retire from the military dur- 
ing these years, and the exaggeration of hearing loss 
may be an attempt to increase retirement benefits or to 
increase compensation already being received. 

There was a low incidence of nonorganic hearing loss 
among retired and active-duty personnel between the 
ages of 18 and 38. During these years, the individual is 
usually becoming involved in his military career. Un- 
less the hearing loss is severe enough to hinder com- 
munication, the thought of exaggerating it is not likely 
to occur. 

Of our dependent population, 12.4% exhibited non- 
organic hearing loss. This is a higher incidence than 
expected from this group. A slight majority (50.3%) of 
this group were between the ages of 12 and 25, and 
were female. The reason for this is not clear, since 
these individuals do not receive any tangible benefits 
for hearing loss. 

In two of the three groups — the recruit and retired/ 
active-duty groups — alleged bilateral hearing loss was 
more prevalent than alleged unilateral hearing loss, 
even though unilateral hearing loss is easier to simu- 
late. Since many hearing impairments in the military 
are caused by noise exposure or noise trauma, which 
usually produces a bilateral hearing loss, most of the 
nonorganic hearing losses in this group are exaggera- 
tions of existing bilateral hearing impairments. While 
hearing loss due to noise exposure is not always sym- 



metrical, it is usually bilateral. 

The dependent group demonstrated more unilateral 
nonorganic hearing impairments than bilateral ones. 
When we examined their health records, we discovered 
that most of these individuals were exaggerating mid- 
dle-ear impairments, which are often unilateral. Thus, 
exaggeration of the unilateral hearing loss prevails in 
this group. 

A large majority (81.8%) of the individuals in our 
study who demonstrated normal hearing bilaterally 
claimed a unilateral hearing loss. The most likely rea- 
son for this is the ease with which a unilateral loss can 
be simulated. 

Some hearing loss was present in each individual of 
the retired/active-duty group. The reason for this is un- 
clear, but one explanation may be that individuals in 
this group are usually older and have been exposed 
over the years to considerably more noise than mem- 
bers of the other two groups, and both these factors 
contribute to hearing loss. 

Summary 

Nonorganic hearing loss was most prevalent in our 
recruit population, and more prevalent in our retired/ 
active-duty group than in the dependent group. Besides 
the recruit, the individual most likely to exaggerate a 
hearing loss in our clinic is the active-duty subject near- 
ing retirement. Next most likely to do so is the retiree 
seeking to increase his chances for compensation for a 
service-connected hearing loss, and he is followed by 
the dependent female between the ages of 12 and 25. 

All physicians should be aware of the possibility of 
nonorganic hearing loss in military personnel. If non- 
organicity is suspected, the patient should be referred 
to an otolaryngologist for further diagnostic testing, 
and to an audiologist for accurate measurement of his 
hearing. 

References 

1. Morrisett LE: Aural rehabilitation program of the U.S. Army 
for the deaf and hard of hearing. Ann Otol Rhinol Laryngol 55:821- 
838, 1946. 

2. Johnson KO, Work WP, McCoy G: Functional deafness. Ann 
Otol Rhino! Laryngol 75:154-170, 1956. 

3. Gleason WJ: Psychological characteristics of the audiologically 
inconsistent patient. Arch Otolaryngol 68:42-46, 1958. 

4. Ventry IM, Chaiklin JB: Functional hearing loss; a problem in 
terminology. ASHA 4:251-254, 1962. 

5. Chaiklin JB, et al: The conditioned GSR auditory speech 
threshold. J Speech Hear Res 2:229-236, 1959. 

6. Hardy WG: Special techniques for diagnosis and treatment of 
psychogenic deafness. Ann Otol Rhinol Laryngol 57:65-95, 1948. 



26 



U.S. Navy Medicine 



'Radiation Cystitis': Benign or 
Malignant Complication? 



LCDR R.E. Duncan, MC, USNR 



Radiotherapy is used widely in the treatment of pel- 
vic malignancies, including tumors of the cervix, 
bladder, rectum, and prostate. For example, of the 
20,000 new cases of carcinoma of the uterine cervix that 
were discovered in the United States in 1976 (/), 80% 
received radiotherapy (2). 

The purpose of irradiation may be curative, adjunc- 
tive to surgery, or palliative. Radiotherapy may be 
given in combination with chemotherapy. In any case, 
irradiation of tumors within the pelvis places adjacent 
organs at risk of radiation reactions (3,4). The effects of 
radiotherapy may also be systemic (5,6). 

Bladder complications from pelvic irradiation were 
first documented in 1927 (7). The clinical course and 
pathological changes in the bladder of the patient un- 
dergoing pelvic irradiation are now well known. Both 
benign and malignant bladder reactions are possible. 

Benign radiation reactions 

Benign bladder complications occur in 1% to 4% of 
patients undergoing pelvic irradiation (8). 

• Acute cystitis may develop within four to six weeks 
after therapy is initiated. Bladder capacity is reduced. 
The mucosa appears erythematous. Histologically, 
injury to basal germinal epithelial cells, hyperemia, 
injury to the fine vasculature and connective tissue, 
interstitial edema, and epithelial desquamation may be 
seen. 

• Subacute trigonal ulceration may develop sudden- 
ly, six months to two years after irradiation. The patient 
complains of painless hematuria, which may be severe. 
Grossly, telangiectases are surrounded by circum- 
scribed areas of blanching. Involvement of larger ves- 
sels leads to increased necrosis of tissue and deeper 



From the Department of Urology, NRMC Camp Lejeune, N.C. 
28542, 



ulceration. Calcifications develop. 

Histologically, the urothelium is irregularly atrophic 
and hyperplastic, as are subepithelial vascular and con- 
nective tissue components. Marked proteinaceous in- 
terstitial edema and a mixed cellular infiltrate may be 
present. 

• Chronic fibrosis may lead to a contracted bladder 
and ureteral strictures, secondary to scarring of the in- 
travesical portion of the ureter, within one to five years 
after radiotherapy. These complications are frequently 
associated with urinary infection. Patients complain of 
severely reduced bladder capacity. The bladder mucosa 
appears atrophic and ulcerated. Fissures or fistulas 
may be present. 

Histologically, the vessels are sclerotic and occluded 
within increasing subepithelial connective tissue. "Ir- 
radiation fibroblasts" are numerous. Differentiation 
between benign radiation reaction and carcinoma is 
difficult at this time. Cytopathologists have found it 
impossible to distinguish malignant from nonmalignant 
irradiated urothelial cells in urinary specimens. 

Secondary ureteral entrapment and obstruction ulti- 
mately lead to pyelonephritis and renal insufficiency. 

Radiation-induced bladder tumors 

Evidence is accumulating that patients receiving 
therapeutic irradiation are at increased risk to develop 
other primary tumors. A similar situation exists for pa- 
tients immunosuppressed after organ transplantation 
(9). 

In the context of the present discussion, a group of 
patients who developed bladder tumors after pelvic ir- 
radiation for carcinoma of the cervix has been identified 
(10). The incidence in this group was found to be 299.9 
per 100,000 — an incidence 57.6 times greater than that 
in a comparable group in the general population. 

The mean interval between irradiation and identifica- 
tion of the vesical malignancy was nine years. Gross 



Volume 69, August 1978 



27 



hematuria was the most common symptom. Changes in 
the excretory urogram (IVP) were noted in 50 % of the 
cases. Lesions were most commonly found on the blad- 
der floor. 

The prognosis for these patients appeared to be the 
same as for patients with similar tumor types in the 
general population. 

Conclusions 

Radiation-induced neoplasms are difficult to identify 
accurately because they are indistinguishable morpho- 
logically from naturally occurring lesions. Irradiation 
may cause premature development of age-dependent 
neoplasms or enhance the lifetime incidence of a tumor. 

The induction time of a specific tumor after radiation 
injury is variable, although it is usually greater than 
five years. 

Although doses greater than 7,000 rads appear to 
enhance benign vesical complications, the critical dose 
for development of a bladder malignancy in this setting 
is unknown. 

It is important to carefully examine patients present- 
ing with radiation reactions of the bladder, in order to 
rule out radiation-induced malignancy — now that this is 



known to occur — as well as recurrent primary tumor. In 
addition, one is constantly reminded to weigh the 
possible risks of therapy against its advantages. 

References 

1. Seidman H, et al: Cancer statistics, 1976: a comparison of 
white and black populations. CA 26:2, 1976. 

2. Silverberg E, Holleb Al: Major trends in cancer: 25-year sur- 
vey. CA 25:2, 1975. 

3. MacMahon CE, Rowe JW: Rectal reaction following radiation 
therapy of cervical carcinoma. Ann Surg 173:264, 1971. 

4. Fehr PE, Prem KA: Postirradiation sarcoma of the pelvic 
girdle following therapy for squamous cell carcinoma of the cervix. 
Am J Obstet Gynecol 116:192, 1973. 

5. Li FP, Cassady R, Jaffe N: Risk of second tumors in survivors 
of childhood cancer. Cancer 35:1230, 1975. 

6. Hutchison GB: Late neoplastic changes following medical irra- 
diation. Radiology 105:645, 1972. 

7. Dean AL: Ulceration of the urinary bladder as a late effect of 
radium application to the uterus. JAMA 89, Oct 1, 1927, p 1121. 

8. Rubin P, Cassarett GW: Urinary tract: the bladders and 
ureters, in Clinical Radiation Pathology. Philadelphia: W.B. 
Saunders Co., 1968, vol 2, p 334. 

9. Penn I, Starzl TE: Malignant tumors arising de novo in im- 
munosuppressed organ transplant recipients. Transplantation 14: 
407, 1972. 

10. Duncan RE, et al: Radiation -induced bladder tumors. J Urol 
118:43, 1977. 



Calling all hands — help! 



Ever felt that U. S. Navy Medicine 
gives too little coverage to your 
Corps, or installation, or facility — 
and too much to others? carries 
little in the magazine of interest to 
you? uses poor photographs and un- 
exciting covers? 

Unfortunately, these are all valid 
citicisms. 

But what you see in the magazine 
is what we get. If only a few people 
contribute news, information, arti- 
cles, and photographs, what ap- 
pears is bound to represent only a 
small segment of the Medical De- 
partment population. 

You can help us do a better job. 

• If you're a frustrated journalist 
and think you'd like to try your hand 
at writing an article, by all means do 
so. If what you send needs editing, 
we'll gladly provide it. 

We particularly need interesting 



feature material, items for "NAV- 
MED Newsmakers," and news of 
activities and programs for "De- 
partment Rounds." We're always 
in need, too, of good professional 
papers — which should, if possible, 
have a Navy angle. 

* If you're a camera buff, why 
not take your camera to work with 
you and see what you can come up 
with for us? We'll give you credit 
for any photograph of yours we use. 

It's a great help, of course, to get 
good pictures taken specifically for 
an article submitted for publication. 
But we need photos on file that we 
can pull out when the need arises: 
sharp, lively, unposed photos of 
Medical Department members at 
work in their various specialties. 

And we especially need interest- 
ing shots that — either cropped or 
used as 's — could make good cov- 



ers for the magazine. 

We can work from black-and- 
white glossy prints (preferably at 
least 5 X 8) or select from your con- 
tact sheets and negatives. We can 
also work from 35-mm transpar- 
encies — and would, in fact, like to 
have a backlog of these on hand. 

• Maybe you're not a writer or 
photographer, but you can still help. 
If there's an interesting program 
going on at your facility — or any 
other news that you think we should 
cover — by all means let us know. 
Drop us a line, or, better yet, give 
us a call (Autovon 294-4316, 294- 
4253, or 294-4214). 

Address all mail to Editor, U.S. 
Navy Medicine, Department of the 
Navy, Bureau of Medicine and 
Surgery (Code 0010), Washington, 
D.C. 20372. 

Thanks! 



28 



U.S. Navy Medicine 



BUMED SITREP 



COOPERATIVE CARE INSTITUTED ... The Depart- 
ment of Defense has inaugurated a new health plan that 
authorizes CHAM PUS to share the cost of many ser- 
vices and supplies provided by civilian medical facilities 
to individuals remaining under primary care from a 
military medical facility. The new plan, known as "co- 
operative care," went into effect on 1 July and is retro- 
active to 1 June 1977. 

In the past, CHAMPUS benefits were considered 
only when a patient had been completely released from 
the jurisdiction of a service medical facility. The patient 
would bear a portion of the cost, and CHAMPUS would 
pay the remainder. 

Now cooperative care can be used when a service 
medical facility determines that a portion of required 
medical care cannot be provided by that facility or any 
local federal medical facility for which the patient is eli- 
gible. To be considered for cooperative care, the benefit 
must fall under CHAMPUS authorized care. 

These are some of the services that may be obtained 
from civilian sources under the cooperative care pro- 
gram: 

• Authorized nondiagnostic medical services, such 
as physical therapy, speech therapy, and radiation 
therapy. 

• Psychotherapeutic/psychiatric care. 

• All care under the CHAMPUS program for the 
handicapped. 

Certain types of medical care provided by civilian 
sources, when the patient remains under primary con- 
trol of a service medical facility that cannot provide 
complete care, will continue to be funded through the 
direct care system. 

Details on the cooperative care plan are available 
from local CHAMPUS representatives. 



STROKE-CARE GUIDE ... A new guide— Funda- 
mentals of Stroke Care — has been issued by the Nation- 
al Institute of Neurological and Communicative Dis- 
orders and Stroke (NINCDS), National Institutes of 
Health. 

The 442-page, soft-cover book results from a 10-year 
effort by the Joint Committee for Stroke Facilities to 
develop authoritative guidelines for appropriate medi- 
cal care {prevention, diagnosis, treatment, and rehabil- 
itation) of potential and actual victims of stroke. The 



joint committee — which includes leaders in the field of 
stroke and representatives of national professional 
organizations working on the problem — was spear- 
headed by the American Neurological Association and 
funded by the Regional Medical Programs Service and 
NINCDS. 

Navy doctors may obtain single copies of the new 
book free, for as long as the supply lasts, from the 
Office of Scientific and Health Reports, NINCDS, Na- 
tional Institutes of Health, Building 31, Room 8A06, 
Bethesda, Md. 20014. The book can also be ordered, for 
$6.50, from the Superintendent of Documents, Govern- 
ment Printing Office, Washington, D.C. 20402. 



FLIGHT SURGEON POLICY ... The Chief of Naval 
Operations has recently reaffirmed the policy that al- 
lows flight surgeons to be in actual control of aircraft as 
part of their practice of occupational and preventive 
medicine. This policy has been promulgated in CNO 
252228Z MAY 78. 



IMMUNIZATION FILM ... "A Gift, an Obligation" is 
a 16-mm color-and-sound film designed to explain to 

parents why it is vital to have their children vaccinated 
against the common childhood diseases. 

The 30-minute film, produced for the American Aca- 
demy of Pediatrics, is available free on loan to health 
care groups. Write to West Glen Films, 565 Fifth Ave- 
nue, New York, N.Y. 10017. 



AUDIT TD?S ... A recently completed audit uncovered 
the following discrepancies: 

• Security of supply storerooms and limited-access 
areas was inadequate to prevent unauthorized entry 
and theft of accountable stock (NAVSUP Manual, par. 
27005-5a). 

• Returning to the supply system polystyrene pack- 
ing acquired from incoming supply shipments would 
result in a cost avoidance of $4,800. 

• Establishment of a formal pallet-control program 
would alert personnel to the advantages of returning 
serviceable pallets to the supply system for reuse 
(NAVSUPINST 4450.23). 



Volume 69, August 1978 



*U.S. GOVERNMENT PRINTING FFI CE : ] 9 78- -Z6 I - 3 79/6 



29 



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